CTC Families in Need – Application - Children's Treatment Centre

Foundation - CTC Families in Need Fund

The Children’s Treatment Centre Foundation of Chatham-Kent has set up a CTC Families in Need Fund to help those closest to us when they need it most. Families with children with extra needs already face additional household costs and are now under additional pressures with the COVID-19 pandemic. This has prompted the CTC Foundation to give families a chance to receive funds towards key issue they are currently facing (groceries, rent/mortage, bills, etc.). Please fill in all fields to the best of your ability. CTC Foundation is committed to protecting your privacy. We promise to keep all the information that you share with us confidential. We only collect personal information for our use as outlined above and will not share, sell or distribute your information with any outside parties. PLEASE NOTE: If you are selected as one of the families to receive support, you will be notified within the week you apply.

Are you the parent and/or guardian of a child or youth that CURRENTLY uses services at the Children's Treatment Centre of Chatham-Kent?*
- YES
- NO
Only those that are a parent or guardian of a child or youth that is a current client of the Children's Treatment Centre of Chatham-Kent qualify to apply towards the CTC Families in Need Fund.
Please provide the client's First and Last name (the child or youth) that is currently receiving services.*
Contact Information
Please fill out the information below if you have answered YES to both questions above. If you are selected as one of the families to receive support, you will be notified within the week you apply.
Name*
First Last
Address*
Street Address Address Line 2 City Province Postal Code
Home Phone*
Alternative Phone
Email*
Form has been filled out by a CTC-CK Staff Member on behalf of the applicant:
- YES
Filled out by CTC-CK Staff only if they are applying on behalf of a client.
Name of CTC-CK Staff filling out application:
First Last
Filled out by CTC-CK Staff only if they are applying on behalf of a client.
Application Questions
Please answer the following questions.
Are you experiencing financial difficulties during this period?*
- YES
- NO
Please describe in 500 words or less how receiving funds from the CTC Families in Need Fund would assist your family in reducing financial stress during the COVID-19 pandemic?*
For example: Special Equipment for your child/youth, prescriptions, groceries, rent/mortgage, utilities, etc.
Agreements
Permission for CTC Foundation to Make Contact*
- I give permission to the CTC Foundation to contact me. I further confirm that the above information is true to the best of my knowledge. I understand that any information collected CTC Foundation will be kept confidential and will not be passed on to any person or agency without my express permission. If you are selected as one of the families to receive support, you will be notified within the week you apply.

CTC Families in Need – Application

Foundation - CTC Families in Need Fund

Contact Information

Application Questions

Agreements